3600 Final

Table of Contents

Benefit Recovery/Benefit Investigation

3610.0000

Food Stamps .............................................................. 1

3610.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (FS) .......... 1

3610.0101

Legal Basis (FS) ................................................................................................... 1

3610.0200

STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (FS) ........................ 2

3610.0300

DEFINITIONS AND TYPES OF OVERPAYMENTS (FS) ........................................ 2

3610.0301

Agency Error Definition (FS)................................................................................. 3

3610.0302

Agency Errors Not Requiring a Referral (FS) ....................................................... 3

3610.0303

Other Instances Not Requiring a Referral (FS) .................................................... 3

3610.0304

Inadvertent Assistance Group Error Definition (FS) ............................................. 3

3610.0306

Inadvertent or Agency Errors Not Requiring Referral (FS) .................................. 3

3610.0307

Suspected Fraud and Intentional Program Violation Definition (FS).................... 3

3610.0308

Suspected Fraud Definition (FS) .......................................................................... 4

3610.0309

Evidence Used to Substantiate Fraud (FS) .......................................................... 4

3610.0310

Court Determination of Fraud (FS) ....................................................................... 4

3610.0311

Hearings Determination of Fraud (FS) ................................................................. 4

3610.0312

Waiver of an Administrative Disqualification Hearing (FS) ................................... 5

3610.0400

OVERPAYMENT AMOUNT (FS) ............................................................................. 5

3610.0401

Overpayment (FS) ................................................................................................ 5

3610.0402

Benefit Recovery Overpayment Calculation (FS) ................................................ 6

3610.0403

Disregards Allowed by Benefit Recovery (FS) ..................................................... 6

3610.0500

DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (FS) ..................... 6

3610.0501

Eligibility Specialist Responsibilities (FS) ............................................................. 6

3610.0503

Benefit Recovery Responsibilities (FS) ................................................................ 7

3610.0504

Benefit Investigations Responsibilities (FS) ......................................................... 7

3610.0505

Division of Public Assistance Fraud Responsibilities (FS) ................................... 7

3610.0600

PERSONS RESPONSIBLE FOR REPAYMENT (FS) ............................................. 7

3610.0700

REPAYMENT (FS) ................................................................................................... 8

3610.0701

Benefit Reduction/Recoupment (FS) .................................................................... 8

3610.0702.01

Benefit Reduction (FS) ..................................................................................... 8

3610.0702.03

Amount to be Recovered (FS) ......................................................................... 8

3610.0703

Offset of Claim (FS) .............................................................................................. 9

3610.0704

Community Service Credit Hours (FS) ................................................................. 9

3610.0707

Civil Action (FS) .................................................................................................... 9

3610.0710

Hearing Requested (FS) ....................................................................................... 9

3610.0711

Compromising Claims (FS) .................................................................................. 9

3610.0800

TRANSMITTAL OF REPAYMENT (FS) ................................................................. 10

3610.0900

DISQUALIFICATION DUE TO COURT/HEARING DECISION (FS) ..................... 10

3610.0901

Disqualification Notice (FS) ................................................................................ 10

3610.0902

Disqualification Periods and Implementation (FS) ............................................. 11

3610.0903

Determining Benefits During Disqualification (FS) ............................................. 12

3610.0904

Administrative Disqualification Hearings (FS) .................................................... 12

3610.1000

BENEFIT INVESTIGATIONS (FS) ......................................................................... 12

Table of Contents

Benefit Recovery/Benefit Investigation

3620.0000

Temporary Cash Assistance ................................... 14

3620.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (TCA) ..... 14

3620.0101

Legal Basis (TCA) .............................................................................................. 14

3620.0200

STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (TCA) ................... 14

3620.0203

Statutes of Limitation for Prosecution (TCA) ...................................................... 14

3620.0300

DEFINITIONS AND TYPES OF OVERPAYMENT (TCA) ...................................... 14

3620.0301

Agency Error Definition (TCA) ............................................................................ 15

3620.0302

Agency Errors Not Requiring a Referral (TCA) .................................................. 15

3620.0304

Inadvertent Assistance Group Error Definition (TCA) ........................................ 15

3620.0306

Inadvertent or Agency Errors Not Requiring Referral (TCA) .............................. 15

3620.0307

Suspected Fraud and Intentional Program Violation Definition (TCA) ............... 15

3620.0309

Evidence Used to Substantiate Fraud (TCA) ..................................................... 16

3620.0310

Court Determination of Fraud (TCA) .................................................................. 16

3620.0400

OVERPAYMENT AMOUNT (TCA) ........................................................................ 16

3620.0404

Overpayment (TCA) ........................................................................................... 16

3620.0405

Reportable Overpayment (TCA) ......................................................................... 16

3620.0406

Beginning Date of Overpayment/Change in Income/Assets (TCA) ................... 17

3620.0406.03

Overpayment - Household Composition Changes (TCA) .............................. 17

3620.0407

Change in Income Results in Benefit Reduction (TCA) ..................................... 17

3620.0408

Changes in Income that Occur in Application Months (TCA) ............................. 17

3620.0500

DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (TCA) ................ 17

3620.0501

Eligibility Specialist Responsibilities (TCA) ........................................................ 17

3620.0503

Benefit Recovery Responsibilities (TCA) ........................................................... 18

3620.0504

Benefit Investigations Responsibilities (TCA)..................................................... 18

3620.0505

Division of Public Assistance Fraud Responsibilities (TCA) .............................. 18

3620.0600

PERSONS RESPONSIBLE FOR REPAYMENT (TCA) ........................................ 18

3620.0700

REPAYMENT (TCA) ............................................................................................... 19

3620.0701

Benefit Reduction/Recoupment (TCA) ............................................................... 19

3620.0702

Benefit Reduction (TCA) ..................................................................................... 19

3620.0703

Offset of Claim (TCA) ......................................................................................... 19

3620.0705

Child Support Credit (TCA)................................................................................. 20

3620.0706

Amount to be Recovered Monthly (TCA) ........................................................... 20

3620.0707

Civil Action (TCA) ............................................................................................... 20

3620.0710

Hearing Requested (TCA) .................................................................................. 20

3620.0800

TRANSMITTAL OF REPAYMENT (TCA) .............................................................. 20

3620.0900

DISQUALIFICATION DUE TO COURT/HEARING DECISION (TCA) .................. 20

3620.0901

Disqualification Notice (TCA).............................................................................. 21

3620.0902

Disqualification Periods and Implementation (TCA) ........................................... 21

3620.0903

Determining Benefits During Disqualification (TCA) .......................................... 22

3620.09045

Administrative Disqualification Hearings (TCA) ............................................. 22

3620.1000

BENEFIT INVESTIGATIONS (TCA) ...................................................................... 23

3630.0000

Family-Related Medicaid ......................................... 24

Table of Contents

Benefit Recovery/Benefit Investigation

iii

3630.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (MFAM) . 24

3630.0101

Legal Basis (MFAM) ........................................................................................... 24

3630.0200

STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (MFAM) ............... 24

3630.0203

Statutes of Limitation for Prosecution (MFAM)................................................... 24

3630.0300

DEFINITIONS AND TYPES OF OVERPAYMENT (MFAM) .................................. 24

3630.0307

Suspected Fraud and Intentional Program Violation Definition (MFAM) ........... 24

3630.0309

Evidence Used to Substantiate Fraud (MFAM) .................................................. 25

3630.0310

Court Determination of Fraud (MFAM) ............................................................... 25

3630.0400

OVERPAYMENT AMOUNT (MFAM) ..................................................................... 25

3630.0410.01

Determination of Medicaid Overpayment (MFAM)......................................... 26

3630.0410.02

Ineligibility Due to Income (MFAM) ................................................................ 26

3630.0410.03

Reasons Other than Income (MFAM) ............................................................ 26

3630.0411

Understated Share of Cost (MFAM) ................................................................... 26

3630.0414

Provider Error (MFAM) ....................................................................................... 27

3630.0500

DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (MFAM) ............ 27

3630.0501

Eligibility Specialist Responsibilities (MFAM) ..................................................... 27

3630.0503

Benefit Recovery Responsibilities (MFAM) ........................................................ 28

3630.0504

Benefit Investigations Responsibilities (MFAM) ................................................. 28

3630.0505

Division of Public Assistance Fraud Responsibilities (MFAM) ........................... 28

3630.0600

PERSONS RESPONSIBLE FOR REPAYMENT (MFAM) ..................................... 28

3630.0700

REPAYMENT (MFAM) ........................................................................................... 28

3630.0706

Amount to be Recovered Monthly (MFAM) ........................................................ 29

3630.0707

Civil Action (MFAM) ............................................................................................ 29

3630.0708

Medicaid Recovery (MFAM) ............................................................................... 29

3630.0709

Amount to be Recovered (MFAM) ...................................................................... 29

3630.0710

Hearing Requested (MFAM)............................................................................... 29

3630.0800

TRANSMITTAL OF REPAYMENT (MFAM) .......................................................... 29

3630.1000

BENEFIT INVESTIGATIONS (MFAM) ................................................................... 30

3640.0000

SSI-Related Medicaid, State Funded Programs ..... 31

3640.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (MSSI, SFP) 31

3640.0101

Legal Basis (MSSI, SFP) .................................................................................... 31

3640.0200

STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (MSSI, SFP) ........ 31

3640.0300

DEFINITIONS AND TYPES OF OVERPAYMENT (MSSI, SFP) ........................... 31

3640.0307

Suspected Fraud and Intentional Program Violation Definition (MSSI, SFP) .... 31

3640.0309

Evidence Used to Substantiate Fraud (MSSI, SFP) .......................................... 32

3640.0310

Court Determination of Fraud (MSSI, SFP)........................................................ 32

3640.0400

OVERPAYMENT AMOUNT (MSSI, SFP) .............................................................. 32

3640.0411

Understated Share of Cost (MSSI) ..................................................................... 32

3640.0412

Overpayment (MSSI, SFP) ................................................................................. 33

3640.0413

Determination of Overpayment (MSSI, SFP) ..................................................... 33

3640.0414

Provider Error (MSSI) ......................................................................................... 33

Table of Contents

Benefit Recovery/Benefit Investigation

3640.0500

DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (MSSI, SFP) ..... 33

3640.0501

Eligibility Specialist Responsibilities (MSSI, SFP) .............................................. 34

3640.0503

Benefit Recovery Responsibilities (MSSI, SFP) ................................................. 34

3640.0504

Benefit Investigations Responsibilities (MSSI, SFP) .......................................... 35

3640.0505

Division of Public Assistance Fraud Responsibilities (MSSI, SFP) .................... 35

3640.0600

PERSONS RESPONSIBLE FOR REPAYMENT (MSSI, SFP) .............................. 35

3640.0700

REPAYMENT (MSSI, SFP) .................................................................................... 35

3640.0708

Medicaid Recovery (MSSI) ................................................................................. 35

3640.0709

Amount to be Recovered (MSSI) ....................................................................... 35

3640.0710

Hearing Requested (MSSI, SFP) ....................................................................... 35

3640.0800

TRANSMITTAL OF REPAYMENT (SFP) .............................................................. 36

3640.1000

BENEFIT INVESTIGATIONS (MSSI, SFP) ............................................................ 36

3650.0000

Child In Care ............................................................. 37

3650.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (CIC) ...... 37

3650.0101 Legal Basis (CIC) .................................................................................................... 37

3650.0300

DEFINITIONS AND TYPES OF OVERPAYMENT (CIC) ....................................... 37

3650.0301

Agency Error Definition (CIC) ............................................................................. 37

3650.0302

Agency Errors Not Requiring a Referral (CIC) ................................................... 38

3650.0304

Inadvertent Assistance Group Error Definition (CIC) ......................................... 38

3650.0306

Inadvertent or Agency Errors Not Requiring Referral (CIC) ........................ 38

3650.0309

Evidence Used to Substantiate Fraud (CIC) ...................................................... 38

3650.0310

Court Determination of Fraud (CIC) ................................................................... 38

3650.0400

OVERPAYMENT AMOUNT (CIC) .......................................................................... 39

3650.0414

Provider Error (CIC) ............................................................................................ 39

3650.0700

REPAYMENT (CIC) ................................................................................................ 39

3650.0710

Hearing Requested (CIC) ................................................................................... 39

3650.1000

BENEFIT INVESTIGATIONS (CIC) ........................................................................ 40

3660.0000

Refugee Assistance Program ................................. 41

3660.0100

BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (RAP) ..... 41

3660.0101

Legal Basis (RAP) .............................................................................................. 41

3660.0200

STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (RAP) ................... 41

3660.0203

Statutes of Limitation for Prosecution (RAP) ...................................................... 41

3660.0300

DEFINITIONS AND TYPES OF OVERPAYMENT (RAP) ..................................... 41

3660.0307

Suspected Fraud and Intentional Program Violation Definition (RAP) ............... 42

3660.0309

Evidence Used to Substantiate Fraud (RAP) ..................................................... 43

3660.0310

Court Determination of Fraud (RAP) .................................................................. 43

3660.0400

OVERPAYMENT AMOUNT (RAP) ........................................................................ 43

Table of Contents

Benefit Recovery/Benefit Investigation

3660.0404

Overpayment (RAP) ........................................................................................... 43

3660.0405

Reportable Overpayment (RAP) ........................................................................ 44

3660.0406.01

Beginning Date of Overpayment - Change in Income (RAP) ........................ 44

3660.0406.03

Overpayment - Household Composition Changes (RAP) .............................. 44

3660.0407

Change in Income Results in Benefit Reduction (RAP) ..................................... 44

3660.0408

Changes in Income that Occur in Application Months (RAP) ............................. 44

3660.0500

DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (RAP) ................ 44

3660.0501

Eligibility Specialist Responsibilities (RAP) ........................................................ 44

3660.0503

Benefit Recovery Responsibilities (RAP) ........................................................... 45

3660.0504

Benefit Investigations Responsibilities (RAP) .................................................... 45

3660.0505

Division of Public Assistance Fraud Responsibilities (RAP) .............................. 46

3660.0600

PERSONS RESPONSIBLE FOR REPAYMENT (RAP) ........................................ 46

3660.0700

REPAYMENT (RAP) .............................................................................................. 46

3660.0701

Benefit Reduction/Recoupment (RAP) ............................................................... 46

3660.0702

Benefit Reduction (RAP) .................................................................................... 46

3660.0706

Amount to be Recovered Monthly (RAP) ........................................................... 46

3660.0707

Civil Action (RAP) ............................................................................................... 47

3660.0710

Hearing Requested (RAP) .................................................................................. 47

3660.0800

TRANSMITTAL OF REPAYMENT (RAP) .............................................................. 47

3660.1000

BENEFIT INVESTIGATIONS (RAP) ...................................................................... 47

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

3610.0000 Food Stamps

This chapter presents policy regarding referrals to Benefit Recovery for determination of

overpayment, fraud, benefit recovery, and disqualification.

In this chapter:

1. "fraud" encompasses intentional program violation,

2. "suspected fraud" refers to client errors pending determination as the result of an

administrative disqualification hearing or court decision,

3. "inadvertent household error" encompasses non-fraud client error,

4. "agency" refers to administrative error or Department errors,

5. "overpayment" will mean both overpayment and overissuance, and

6. "Benefit Investigations" refers to the Department's pre-eligibility fraud

screening and investigation program.

3610.0100 BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (FS)

The need to recover improperly issued benefits and to identify and prosecute individuals who

willfully and fraudulently obtained, or attempted to obtain, these benefits led to the development

of a statewide system for the identification, investigation, determination, and collection of public

assistance overpayments.

This system is comprised of:

the Benefit Investigations Program (BI);

the Benefit Recovery (BR) Program; and

3. the Division of Public Assistance Fraud (DPAF).

(BI) conduct pre-eligibility, fraud screening, investigations and refer cases of attempted fraud

to Administrative Disqualification Hearings. Referrals from BI to the Office of the Secretary

Inspector General Hearings (OSIH) are no program loss and program loss cases. Cases

suspected of past overpayment from suspected fraud are referred by BI directly to the

Division of Public Assistance Fraud (DPAF) by using the FLORIDA BVBR screen.

BR establishes the existence, circumstances and amount of public assistance overpayment and

pursues recovery of overpayments from members of the overpaid assistance group or person

responsible for causing the overpayment (i.e., authorized representative).

The DPAF handles fraud investigations and referrals to the State Attorneys and administrative

disqualification hearings where appropriate in all programs covered in Chapters 409 and 414,

Florida Statutes.

3610.0101 Legal Basis (FS)

The legal bases for fraud and recovery of overpayments are established by:

1. Florida Statutes, Sections 409.325/414.41[1996], and 409.335/414.39[1996];

2. Section 7 CFR 273.18 of the Code of Federal Regulations;

3. Title IV-A of the Social Security Act;

4. Section 45 CFR 233; and

5. Florida Administrative Code Chapter 65A-1.

According to Section 409.325/414.41[1996], Florida Statutes, "Any person who knowingly fails by

false statement, misrepresentation, impersonation, or other fraudulent means, to disclose a

material fact used in making a determination as to such person's qualification to receive aid or

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

benefits under any state or federally funded assistance program, or fails to disclose a change in

circumstances in order to obtain or continue to receive under such program aid or benefits to

which he is not entitled, or who knowingly aids and abets another person in the commission of

any such act is guilty of a crime and will be punished as provided in Subsection (5)." This

subsection provides that assistance wrongfully sought or received which is valued at less than

$200 in a 12-month period will be punishable as a misdemeanor of the first degree. Assistance of

$200 or more in a 12-month period will be punishable as a third-degree felony.

According to Section 409.335/414.39[1996], Florida Statutes, "Whenever it becomes apparent

that any person has received any assistance or benefits under this chapter to which he is not

entitled, through either simple mistake or fraud, the Department shall take all necessary steps to

recover the overpayment".

According to Section 414.095(16), Florida Statutes, an applicant who meets an error prone

profile, as determined by the Department, is subject to pre-eligibility fraud screening as a means

of reducing misspent funds and preventing fraud. The Department created an error prone or

fraud prone case profile within its public assistance information system and shall screen each

application for Temporary Cash Assistance under the Welfare Transition Program against the

profile to identify cases that have a potential for error or fraud. Each case so identified is subject

to pre-eligibility fraud screening.

According to Section 414.39 (10), the Department shall create an error-prone case profile within

its public assistance information system and shall screen each application for public assistance,

including food stamps, Medicaid, and Temporary Cash Assistance, against the profile to identify

cases that have a potential for error or fraud. Each case so identified shall be subjected to pre-

eligibility fraud screening.

3610.0200 STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (FS)

For agency error cases, claims are established when 12 months or less have elapsed between

the month the overpayment occurred and the month the overpayment was initially discovered by,

or reported to, the Department.

For client error, or inadvertent household error, a claim will be established when 72 months or

less have elapsed between the month an overpayment occurred and the month the overpayment

was initially discovered by, or reported to, the Department.

Intentional Program Violation claims will be established or calculated back to the month that the

fraudulent activity initially occurred unless that change occurred more than 72 months prior to the

date it was initially discovery by or reported to, the Department.

3610.0300 DEFINITIONS AND TYPES OF OVERPAYMENTS (FS)

An overpayment exists when an individual receives benefits in an amount greater than the

amount the individual was eligible to receive.

An overpayment may be the result of:

1. agency error;

2. client error, or inadvertent household error;

3. fraud, or intentional program violation; or

4. any combination of the above.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

3610.0301 Agency Error Definition (FS)

Agency error occurs when an incorrect benefit is received by or paid on behalf of an individual

due to an error made on the part of the agency.

Agency error overpayment can occur as a result of:

1. a misapplication of policy,

2. a calculator error,

3. computer processing error (for example, an interception and/or cancellation that did not

take place),

4. failure to take prompt action on available information,

5. insufficient time to give adverse action notice to the assistance group,

6. more income received in a prospective month than was anticipated, or

7. some other error over which the Department has control.

3610.0302 Agency Errors Not Requiring a Referral (FS)

A claim will not be established for the sole reason that the Department failed to ensure that an

assistance group or individual:

1. signed the application form,

2. completed a current work registration form,

3. completed a timely review,

4. failed to provide a required form for completion, or

5. failed to provide a written Declaration of Citizenship.

3610.0303 Other Instances Not Requiring a Referral (FS)

In addition to the reasons listed in passage 3610.0302 for agency errors not requiring a referral, a

claim will not be established for the sole reason that the assistance group or individual failed to

report a change that it was not required to report.

3610.0304 Inadvertent Assistance Group Error Definition (FS)

Inadvertent assistance group error, also known as client error, is an overpayment caused by a

misunderstanding or an unintended error on the part of the assistance group or individual.

Inadvertent assistance group (client) error overpayment can occur as a result of individual:

1. failure to provide the Department with correct or complete information,

2. failure to report to the Department changes in the filing unit circumstances, and

3. receipt of benefits (or more benefits than were entitled to be received) pending a fair

hearing decision because the assistance group requested a continuation of benefits

based on the mistaken belief that it was entitled to such benefits.

3610.0306 Inadvertent or Agency Errors Not Requiring Referral (FS)

A BR referral will not be made, or a claim established on cases when agency or client errors

results in overpayment of less than $400 in food stamps.

3610.0307 Suspected Fraud and Intentional Program Violation Definition (FS)

Fraud exists if:

1. overpayment was caused by an intentional action on the part of the assistance group or

individual in an attempt to receive additional benefits for which they are not entitled, or

2. there was an intent to defraud that does not result in an overpayment.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

Fraud, or attempted fraud, can only be determined by a court or hearings official. Situations

pending such a determination are considered suspected fraud.

Fraud overpayment can occur as a result of the assistance group:

1. misrepresenting information,

2. concealing information,

3. withholding information pertinent to determining eligibility including untimely reporting,

4. failing to report a change in order to continue to receive benefits for which they are not

entitled, or

5. intentionally altered or changed documents to obtain benefits to which the assistance

group was not entitled.

3610.0308 Suspected Fraud Definition (FS)

In addition to those examples of fraud listed in passage 3610.0307, fraud also exists if the

assistance group or individual intentionally:

used benefits to buy nonfood items (such as alcohol or cartons of cigarettes);

used or possessed improperly obtained benefits;

traded or sold benefits; or

committed any act that constitutes a violation of the Food Stamp Act, the Food

Stamp Program Regulations, or any state statute relating to the use, presentation,

transfer, acquisition, receipt, or possession of food stamp benefits.

3610.0309 Evidence Used to Substantiate Fraud (FS)

Written verification of the unreported income received by the assistance group may be used to

substantiate intent. Wage and unearned income information supplied through Data Exchange to

the eligibility specialist is not to be considered verified upon receipt, with the exception of

SSA/SSI and BENDEX information.

Verification that the assistance group member understood their responsibility for reporting the

information in question may be used to substantiate intent. This verification could include:

1. the signed application,

2. the acknowledgement of rights and responsibilities,

3. previously submitted change report form(s), or

4. recorded and/or verified instances of other changes reported by the assistance group

which could or did affect the benefits received.

An application or change report form submitted during the period fraud is suspected which omits

the information that resulted in the overpayment may be used to substantiate intent.

Sworn testimony by the eligibility specialist or other individuals may also be used to substantiate

intent. It is important that the eligibility specialist be able to identify the individual.

These examples are not all inclusive; other types of evidence may also be used.

3610.0310 Court Determination of Fraud (FS)

Fraud must be determined by a court of appropriate jurisdiction. The determination must be an

adjudication of guilt or adjudication withheld and a Disqualification Consent Agreement must have

been signed by the individual charged with fraud.

3610.0311 Hearings Determination of Fraud (FS)

Fraud, or attempted fraud, is also determined by an administrative hearing official. This

determination must be stated in the final order of the hearings official, which may either report the

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

evidence presented in the hearing, the findings and conclusions of the Hearing Officer, or include

a waiver signed by the individual charged with intent to commit fraud.

3610.0312 Waiver of an Administrative Disqualification Hearing (FS)

The State agency shall provide written notification to the household member suspected of

Intentional Program Violation that the member can waive his/her right to an administrative

disqualification hearing. An Administrative Disqualification waiver provided to the household

member which informs him/her of the possibility of waiving the administrative disqualification

hearing shall include, at a minimum:

• An opportunity for the accused individual to specify whether or not he/she admits to the

facts as presented by the State agency. This opportunity shall consist of the following

statements, or statements developed by the State agency which have the same effect,

and a method for the individual to designate his/her choice:

(1) I admit to the facts as presented, and understand that a disqualification penalty will

be imposed if I sign this waiver; and

(2) I do not admit that the facts as presented are correct. However, I have chosen to

sign this waiver and understand that a disqualification penalty will result; and

(3) I have read this notice and wish to exercise my rights to have an administrative

hearing.

• The date that the signed waiver must be received by the State agency to avoid the

holding of a hearing and a signature block for the accused individual, along with a

statement that the head of household must also sign the waiver if the accused individual

is not the head of household, with an appropriately designated signature block.

Each waiver packet sent to the household member will include a copy of the waiver, a cover

letter, and a notification of Intent to Disqualify.

3610.0400 OVERPAYMENT AMOUNT (FS)

The eligibility specialist determines if an overpayment appears to exist, and a referral is

completed and transmitted to BR for all agency error and household error overpayments. All

suspected fraud referrals are transmitted to DPAF for review and possible investigations. BR will

determine the overpayment based on the best available information. If there is no acceptable

information available on which to establish a corrected benefit amount, then insufficient evidence

exists and no claim can be established by BR.

3610.0401 Overpayment (FS)

The beginning date of overpayment is determined as follows:

If the overpayment resulted from information provided or withheld at the time of application or

reapplication, any incorrect benefits received based on that application would be included as part

of the overpayment.

If the assistance group member fails to report a change in the assistance group's circumstances,

the first month affected by the failure to report will be the first month in which the change would

have been effective had it been timely reported.

The beginning date of overpayment is determined by applying the "10-10-10 rule" to the date the

change occurred. * The 10-10-10 rule allows the individual 10 calendar days from the date the

change occurred to report the change to the agency. The agency then has 10 calendar days to

act on the change and 10 calendar days to allow for "adverse" notice to the individual. In most

instances, this procedure would result in overpayment beginning the second month after the

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

month of change. The exception would be when the change falls on the 1st day of the month in a

31-day month.

Note: Date of change is defined as the date the actual circumstance occurred; for income, this is

the date the first paycheck reflecting the change is received. For the Food Stamp Program, the

date of change is defined as the date the individual began the job, not the date of the first

paycheck; however, BR looks at the date of the first paycheck for determining the beginning date

of overpayment.

3610.0402 Benefit Recovery Overpayment Calculation (FS)

To determine correct monthly benefit levels, the BR claims examiner will use the same budget

month and actual or converted budgeting methods to determine gross earned or unearned

income received during the month.

3610.0403 Disregards Allowed by Benefit Recovery (FS)

Assistance groups will be allowed the earned income disregards and standard disregards in

effect during the overpayment month. The food stamp earned income disregard is not allowed in

any household error budgets completed after October 1, 1996. The disregards are also not

allowed in suspected fraud budgets.

Dependent care and medical expense disregards may be included in calculating the budget.

Verification for these must be recorded in the case file.

Shelter costs disregards and excess shelter disregards will also be considered in the calculation

of excess benefits received.

Any deductible expenses which, were previously verified and correctly included in the calculation

of benefits will be included in the overpayment budget.

If the assistance group provides adequate verification of deductible expenses which were not

included in the calculation of benefits at the time of overpayment, the expenses will be considered

in the overpayment calculations.

3610.0500 DEPARTMENT STAFF OVERPAYMENT RESPONSIBILITIES (FS)

Overpayment responsibilities of the eligibility specialist, Benefit Recovery, Benefit Investigations,

and the Division of Public Assistance Fraud are provided in passages 3610.0501 through

3610.0505.

3610.0501 Eligibility Specialist Responsibilities (FS)

The eligibility specialist must establish that overpayment has occurred by obtaining and recording

the following facts in running record comments prior to initiating a referral to BR on the FLORIDA

BVBR screen:

1. how the overpayment was discovered,

2. the date of discovery,

3. who received the income/asset/status change,

4. the date the income or change started and/or stopped,

5. the cause of overpayment,

6. the estimated length,

7. any explanation given for failure to provide information accurately or in a timely manner,

8. corrective action taken and the date such action(s) was taken, and

9. instances involving misuse of food stamps (the dates and source of the referral must be

recorded).

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

The eligibility specialist must take necessary action to ensure that correct payment will be made

for the current situation or that cancellation of benefits is effective in accordance with policy prior

to referral to BR. This step includes doing a partial eligibility review on the fraudulent factors

when fraud is suspected except when the suspected fraud was identified during the complete

eligibility review process. If overpayment was discovered as a result of Data Exchange, follow

the policy in Chapter 3000 prior to referral to BR.

The eligibility specialist must then verify that the individual was actually receiving assistance

during the time the suspected overpayment.

The eligibility specialist must:

1. adjust the current benefit if appropriate;

2. complete a referral via the FLORIDA AIFP to the Benefit Investigations for cases in which

an error/fraud prone profile match occurs at the application/reapplication;

certification/recertification process;

3. complete the Benefit Recovery Referral (BVBR) if an overpayment is determined; and

4. respond to BR requests for any additional information within 10 calendar days.

3610.0503 Benefit Recovery Responsibilities (FS)

BR is responsible for the establishment of all overpayment claims and the maintenance of all

recoupment and recovery activities.

As the Department's liaison with DPAF, BR is responsible for the programming of the electronic

submission of suspected fraud referrals to DPAF via FLORIDA BVBR. When the investigation

results in sufficient evidence of suspected fraud, DPAF completes a referral for prosecution to the

appropriate State Attorney or to the OSIH. This process is also completed on cases identified by

PAF through independent program reviews.

BR is the "Custodian of the Case Record" for the overpayment claim from the date of request for

an Administrative Disqualification Hearing or court hearing to final disposition.

3610.0504 Benefit Investigations Responsibilities (FS)

The Department will conduct pre-eligibility fraud screening and investigation of suspected fraud

cases at the application/reapplication, certification/recertification process and prior to benefit

approval. The Department is responsible for referring appropriate cases to the OISH, Hearings

for an Administrative Disqualification Hearing. Cases in which individuals have received benefits

due to suspected fraud will be referred directly to DPAF by BI staff by completion of the FLORIDA

BVBR screen.

3610.0505 Division of Public Assistance Fraud Responsibilities (FS)

DPAF has the responsibility to handle investigations of suspected fraud in all programs covered

in Chapter 409, Florida Statutes (FS). This includes the Food Stamp Program. The Department

has a contract with DPAF to investigate fraud in the public assistance programs. Federal

matching monies are utilized to fund this activity.

PAF has the responsibility for investigating and referring cases of suspected fraud for prosecution

to the State Attorney and for referring cases to the OSIH for Administrative Disqualification

Hearings.

3610.0600 PERSONS RESPONSIBLE FOR REPAYMENT (FS)

All members who were adult members (18 years of age or older) of the assistance group at the

time the overpayment occurred will be jointly and individually liable for the value of any

overpayment of benefits.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

BR may pursue recovery action against any assistance group which contains a member who was

an adult member of the original assistance group at the time the overpayment occurred. This can

include retention of restored benefits owed to the assistance group as an offset against the

overpayment claim.

If a change in assistance group membership occurs, BR will pursue recovery action against

current assistance groups containing:

1. a majority of the individuals who were assistance group members at the time the

overpayment occurred; and

2. any adult member of the assistance group or adult relative who received the

overpayment.

3610.0700 REPAYMENT (FS)

Recovery of amounts of overpayment will be made by one or more of the following methods:

1. lottery intercepts,

2. lump sum and installment payments,

3. benefit reduction,

4. offset of lost benefits,

5. credit for community service hours completed (food stamps with court order only),

6. child support credit (AFDC only), and

7. federal benefits and tax intercepts.

BR must notify the overpaid assistance group of the amount and cause of overpayment as well

as the various repayment methods available.

BR must then allow a minimum of 30 calendar days for the assistance group to respond prior to

initiating recovery activity. If the recipient is active, benefit reduction will begin immediately.

Passages 3610.0701 through 3610.0710 describe methods of repayment.

3610.0701 Benefit Reduction/Recoupment (FS)

Benefit reduction is used to recover overpayment from active recipients.

When a current recipient's court ordered amount is greater than the amount of benefit reduction,

the excess must be paid by direct reimbursement.

3610.0702.01 Benefit Reduction (FS)

Recoupment percentages are automatically set by the claim type and will start automatically.

EDBC will be run automatically to initiate recoupment.

The amount of the monthly payment will change if the assistance group's allotment changes.

FLORIDA will automatically adjust the recoupment amount when the allotment changes.

3610.0702.03 Amount to be Recovered (FS)

The amount of food stamps to be recovered each month through allotment reduction will be

determined as shown below:

1. For agency error and non-fraud client error claims, the amount of food stamps recovered

each month will be 10 percent of the assistance group's monthly allotment or $10 per

month, whichever is greater.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

2. For cases involving fraud, the amount will be 20 percent of the assistance group's

monthly allotment or $10, whichever is greater.

3610.0703 Offset of Claim (FS)

The Department is required to restore benefits to a household that has lost benefits because of

an agency error.

Federal regulations stipulate that in the event a claim has been established against a household,

any benefits to be restored to the household at a later date can be offset against the claim

amount. If the amount of benefits to be restored exceeds the claim amount, the remaining

balance will be restored to the household and the claim will be satisfied.

Exception: Retroactive benefits are not offset against outstanding claims.

3610.0704 Community Service Credit Hours (FS)

Individuals who have been court ordered to complete community service hours as part of their

restitution may have the amount of their overpayment "compromised" (reduced) by the dollar

value of the service they perform. Each hour is assumed to be worth minimum wage unless

specified otherwise by the court. Documentation that all hours ordered have been completed

must be received by the State Attorney's office prior to adjusting the overpayment amount.

3610.0707 Civil Action (FS)

All steps necessary to institute civil action are taken when BR unit determines that such action is

required to recover a TCA, AFDC, or Food Stamp Program overpayment from a former recipient

or from individuals in Medical Assistance Only cases.

3610.0710 Hearing Requested (FS)

When an individual requests a fair hearing regarding an overpayment, the request for hearing

screen (CLFH) must be completed by the BR Hearing Specialist team within three working days

of the date the request was received. When the request is in writing, a copy must be sent to the

OSIH along with a copy of the "statement of matters" form (i.e., a Notice of Decision, Intent to

Recover, etc.).

When an individual requests a hearing in response to the Notice of Case Action regarding the

amount of repayment, the BR unit is responsible for submitting the Request for Hearing to OSIH.

If the individual requests a timely hearing from the date of the Notice of Case Action, the benefit

reduction will be stopped until the conclusion of the Hearing and a final decision has been made

by OSIH. BR must be notified of the hearing date, time and location. When the final order is

received via Document Imaging to the dedicated workgroup box, the BR staff member is notified

via an alert and will take the appropriate actions. If the individual contacts the eligibility specialist

in response to a BR generated notice or action, the eligibility specialist should refer the individual

to the BR unit for initiation of the Fair Hearing request.

3610.0711 Compromising Claims (FS)

A claim or any portion of a claim may be compromised except for court ordered restitutions or

intentional program violations. Individuals with an overpayment claim may request a compromise

of their claim at any time after they are notified of the claim. The Department will determine the

economic household circumstances reasonably demonstrate the overpayment claim will not be

paid within three years of being notified of the overpayment claim and will compromise to zero

dollars when at least one of the following is present:

1. The death or prognosis of death of any liable individual within three years of being

notified;

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

2. Pending litigation in a court, including a bankruptcy court, that involves any liable

individual’s obligation to repay the overpayment within three years of being notified;

3. Any liable individual is sentenced to a period of incarceration that will expire after the

three-year period the overpayment is expected to be paid; or

4. The liable individual(s) sole household’s income is based only on either age or disability

projecting a fixed, limited economic potential to repay the overpayment within three

years.

Verification of the above criteria is required.

Note: Liable individual(s) can request a compromise even if they do not meet the above criteria.

The request and any other related information provided must clearly show the overpayment claim

will not be paid within the three-year period. The Department will not speculate about the liable

individual’s ability to repay the overpayment.

3610.0800 TRANSMITTAL OF REPAYMENT (FS)

All repayments must be directed through BR.

Repayments may be collected by the local office; however, the repayment must be forwarded to

BR within 24 hours.

Note: The individual must be informed that future payments must be payable to DCF and mailed

to:

P.O. Box 4069

Tallahassee, FL 32315-4069

3610.0900 DISQUALIFICATION DUE TO COURT/HEARING DECISION (FS)

Individuals found to have committed fraud by a court will be disqualified for the length of time

addressed by the court.

In addition to disqualification periods, the court may impose fines up to $10,000, imprisonment up

to five years, or both. The individual may also be subject to further prosecution under other

applicable state and federal laws.

If the court makes an adjudication of guilt but fails to impose a disqualification period, or if

adjudication of guilt is withheld or the individual enters the pre-trial intervention or diversion

program and signs a disqualification consent agreement, the Benefit Recovery unit will impose

disqualification penalties in accordance with the policy presented in passage 3610.0902.

Individuals found to have committed fraud by a hearings official through the administrative

disqualification hearing process or who sign a waiver of administrative disqualification hearing will

be disqualified in accordance with the policy presented in passage 3610.0902.

3610.0901 Disqualification Notice (FS)

BR will disqualify only the individual found to have committed or attempted to commit fraud and

not the entire assistance group. On an active case, BR will inform the assigned BR claims

examiner of the disqualification penalties against the individual. Notification must be provided to

the payee of the assistance group regarding the effect that the disqualification has on the

assistance group’s benefits.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

3610.0902 Disqualification Periods and Implementation (FS)

The disqualification period for an eligible assistance group member will begin with the first month

following the date the agency receives written notification of the hearing’s decision, the date of

the signed Waiver of Administrative Disqualification Hearing or within 45 calendar days from the

date of receipt of a state attorney/court disposition. There is no requirement for notification

through certified mail. The Department is not required to give the assistance group notice of

adverse action prior to imposing the disqualification.

Disqualification periods, when specified in a court order, must be followed as defined by the court.

In the absence of court ordered specifications, use the following program specific policies to

determine disqualification periods.

FS disqualification periods:

In the Food Stamp Program there are several program violations, which have very stringent

disqualification periods; these include the sale of controlled substances (illegal drugs), firearms,

ammunition and/or explosives.

For program violations related to the use or receipt of food stamps in a transaction involving the

sale of a controlled substance, the disqualification periods are:

1. 24 months for the first violation, and

2. permanent disqualification for the second violation.

For program violations related to the use or receipt of food stamps in a transaction involving the

sale of firearms, ammunition, or explosives, the disqualification period is permanent for the first

violation.

For program violations involving trafficking of food stamps in the amount of $500 or more, the

disqualification period is permanent for the first violation.

For program violations involving fraudulent statements or representations regarding identity or

residence in order to receive multiple benefits, the disqualification period is 10 years for each

violation.

In addition to these specific program violations there are two situations where an individual is

automatically disqualified due to their status as a fleeing felon or probation violator or having a

felony drug trafficking conviction.

An individual, who is a fleeing felon or probation violator, is disqualified from participation in the

Food Stamp Program as long as they are a fleeing felon or probation violator.

An individual who was convicted of a drug trafficking felony including agreeing, conspiring,

combining, or confederating with another person to commit the act committed after 8/22/1996 is

permanently disqualified from participation in the Food Stamp Program. If the illegal behavior

that led to the conviction occurred on or before 8/22/96, the disqualification does not apply

regardless of the date of the conviction. If a court expunges the felony drug trafficking conviction,

the individual is not subject to the disqualification. The individual must provide proof of the

expungement.

For all other Food Stamp Program violations, the disqualification periods are:

1. 12 months for the first violation,

2. 24 months for the second violation, and

3. permanent disqualification for the third violation

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

Note: In instances where the food stamp fraud occurred prior to April 1, 1983, a three-month

disqualification period is applied, regardless of the type of violation.

3610.0903 Determining Benefits During Disqualification (FS)

The income, expenses, and assets of a disqualified individual will be counted in their entirety for

determining benefits for the remainder of the assistance group.

The individual's needs will not be included when determining the benefit level of the remaining

members.

In no event will the assistance group's benefits be increased as a result of a member's

disqualification.

3610.0904 Administrative Disqualification Hearings (FS)

The OSIH will send a written advance notice of administrative disqualification hearing by regular

mail to the assistance group member suspected of fraud at least 30 calendar days in advance of

the scheduled hearing date. A waiver of administrative disqualification hearing form will be

provided with the notice.

A disqualification hearing will not be held if the individual signs and returns the waiver of

administrative disqualification hearing accepting the disqualification penalty for the specified time

period on the waiver form. If the individual does not return a signed waiver, or indicates they

would like a hearing, an administrative disqualification hearing will be held.

A pending disqualification hearing will not affect the assistance group's or individual's right to be

determined eligible and participate in the program. Eligibility and benefit levels will be calculated

according to standard rules and procedures.

OSIH will base the determination of fraud on clear and convincing evidence which demonstrates

that the assistance group member(s) intentionally committed, or attempted to commit, fraud. The

OSIH decision must:

1. specify the reasons for the decision,

2. identify the supporting evidence,

3. identify the pertinent Code of Federal Regulations, and

4. respond to reasoned arguments made by the assistance group member or representative

consistent with current policy.

If OSIH rules the assistance group member committed or attempted to commit fraud, the member

will be disqualified in accordance with the established disqualification periods.

In addition to updating the disqualification hearings update screen on FLORIDA, OSIH will send a

copy of the hearing decision to the dedicated BR workgroup in Document Imaging. Each Final

Order will be sent to the Collections Unit, who will initiate disqualification action. BR will initiate

disqualification upon receipt of notification that the disqualification hearings update screen has

been completed by OSIH to show a hearings decision.

BR will take the appropriate FLORIDA action to remove the member from the assistance group,

recalculate the benefit level, and send the Notice of Case Action.

3610.1000 BENEFIT INVESTIGATIONS (FS)

Benefit Investigations (BI) is an extension of the Department's public assistance eligibility process

and operates within the purview of 7 CFR 273, 45 CFR 233, and Sections 414.095(16) and

414.39(10), Florida Statutes. It is a program designed to combat fraud and reduce misspent

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: FS

dollars in the Department's public assistance programs. Probable error prone cases are

identified at the pre-eligibility (application/reapplication, certification/recertification) phase of the

public assistance program. Once a case is identified as meeting error prone criteria, it is referred

to the BI. BI reviews the information provided by the individual or the authorized representative

and verifies and documents the finding of fact as it relates to the information provided by the

individual and the eligibility factors used to determine the individual's level of participation. Once

verification and documentation are completed, the recipient is given an opportunity to explain

contradictory information and an eligibility determination is made.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: MFAM

3620.0000 Temporary Cash Assistance

This chapter presents policy regarding referrals to Benefit Recovery (BR) for determination of

overpayment, fraud, benefit recovery, and disqualification.

In this chapter:

1. "fraud" encompasses intentional program violation,

2. "suspected fraud" refers to client errors pending determination as the result of an

administrative disqualification hearing or court decision,

3. "inadvertent household error" encompasses nonfraud client error,

4. "agency" refers to administrative error or Department errors,

5. "overpayment" will mean both overpayment and overissuance, and

6. "Benefit Investigations" refers to the Department's pre-eligibility fraud screening and

investigation program.

3620.0100 BENEFIT RECOVERY/BENEFIT INVESTIGATIONS BACKGROUND (TCA)

Background information is provided in passage 3610.0100.

3620.0101 Legal Basis (TCA)

The legal basis is provided in passage 3610.0101.

3620.0200 STATUTES OF LIMITATION FOR ESTABLISHING CLAIMS (TCA)

For agency error cases, a claim is limited to 12-months prior to the month the overpayment was

initially discovered by, or reported to, an eligibility specialist.

For inadvertent household error cases, a claim is limited to 72 months prior to the month the

overpayment was initially discovered by, or reported to, an eligibility specialist.

Intentional Program Violation (non-prosecution) claims will be established or calculated back to

the month that the fraudulent activity initially occurred unless that change occurred more than 72

months prior to the date it was initially discovery by or reported to, the Department.

3620.0203 Statutes of Limitation for Prosecution (TCA)

Possible fraud overpayment is restricted because of the time limitations for criminal prosecution

of fraud. A fraud case must be prosecuted no later than two years (misdemeanor) or three years

(felony) from the date the fraud occurred. Therefore, the State Attorney will not consider

prosecuting any case in which at least part of the fraud period did not occur less than two (or

three) years prior to filing with the State Attorney.

3620.0300 DEFINITIONS AND TYPES OF OVERPAYMENT (TCA)

An overpayment exists when an individual receives benefits in an amount greater than the

amount the individual was eligible to receive.

An overpayment may be the result of:

1. agency error,

2. client error, or inadvertent household error,

3. fraud, or intentional program violation, or

4. any combination of the above.

Chapter: 3600 Benefit Recovery/Benefit Investigations Program: MFAM

3620.0301 Agency Error Definition (TCA)

Agency error occurs when an incorrect benefit is received by or paid on behalf of an individual

due to an error made on the part of the agency.

Agency error overpayment can occur as a result of:

1. a misapplication of policy,

2. a calculator error,

3. computer processing error (for example, an interception and/or cancellation that did not

take place),

4. failure to take prompt action on available information,

5. insufficient time to give adverse action notice to the assistance group,

6. more income received in a prospective month than was anticipated, or

7. some other error over which the Department has control.

3620.0302 Agency Errors Not Requiring a Referral (TCA)

A claim will not be established for the sole reason that the Department failed to ensure that an

assistance group or individual:

1. signed the application form,

2. completed a current work registration form,

3. was certified in the correct project area,

4. completed a timely review,

5. failed to provide a required form for completion, or

6. failed to provide a written Declaration of Citizenship.

3620.0304 Inadvertent Assistance Group Error Definition (TCA)